Provider Demographics
NPI:1053750547
Name:RETTIG, ERIC MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:MICHAEL
Last Name:RETTIG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-3304
Mailing Address - Country:US
Mailing Address - Phone:814-946-3937
Mailing Address - Fax:814-944-8265
Practice Address - Street 1:1418 11TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-3304
Practice Address - Country:US
Practice Address - Phone:814-946-3937
Practice Address - Fax:814-944-8265
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002781152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028354500001Medicaid
PA1028354500001Medicaid